Pondering Prostate Screenings

Screening for prostate cancer is performed in an effort to diagnose the disease in its early stages, when it most likely to be cured. Screening usually consists of a digital rectal exam to feel the size and shape of the gland and a PSA test.

PSA, or Prostate Specific Antigen, is a blood test that has been used for many years to detect prostate cancer. PSA is a protein that is produced by both benign prostate tissue and by cancerous prostate tissue. A small amount of PSA is released into the blood and can be measured. Cancerous cells usually make more PSA than non-cancerous cells and result in an elevated level of PSA. However, there are benign conditions of the prostate, such as an enlarged gland (or BPH) as well as inflammation of the gland, that can cause an elevation of PSA. There are also certain medications that can cause an elevated PSA.

When the PSA is elevated, but there’s no cancer, that’s called a false positive. On the other hand, some prostate cancers don’t make much PSA, so the blood level may not be elevated. When the PSA is normal, but the patient has prostate cancer, that’s a false negative. You can begin to see that, like so many things in life, the PSA test isn’t perfect.

Recently, the U.S. Preventive Services Task Force recommended against routine PSA screening. The Task Force is a group of scientific experts who evaluate scientific studies and make recommendations about screening tests. They give screening tests a grade, just like in school, and they gave PSA a grade of “D”. Not very good.

They felt that the evidence for PSA testing was based on some weak data. Two large studies did not show that routine PSA testing decreases the likelihood of a man dying from prostate cancer. They were also concerned about the fact that, once an elevated PSA is found, it results in testing, procedures and treatments that may not benefit the patient or extend his life. In some cases, there can be complications; some of them severe.

They were also concerned about over treatment. Almost all men with a prostate cancer detected by a PSA test will get some type of treatment, but some men with prostate cancer may have such a slow-growing tumor that they would never need treatment.

Those who disagree with the task force – and there are some very smart people who do – argue that early detection saves lives and allows for less aggressive treatment that may involve less pain, side effects and complications. They make the point that the task force focused on survival and the complications of treatment, but ignored the illness associated with living with advanced cancer – cancers that might have been detected and treated earlier with PSA screening. They also point out that the task force did not consider men in high-risk populations, such as African Americans, nor did they consider that there are studies showing that prostate cancer deaths and cases presenting at an advanced stage have decreased in the 20 years that PSA screening has been done.

To make matters more complicated, the absolute best treatment for prostate cancer is not 100% clear. In some cases, observation or “watchful waiting” can be done safely. Surgery can be done in a number of different ways. There are drugs that can slow or stop the progress of the disease. Different types of radiation treatments are available. In many cases, there is no one “best” treatment.

So, what should you do? One thing all of the experts agree on is that a man should make an informed decision about PSA testing after talking with his doctor or other health professional. You should consider your lifestyle and your personal beliefs and preferences for health care. Your age and overall health matter. Men older than 80 and those with a medical condition that makes it unlikely that they will live for 10 more years probably shouldn’t be screened. African American men have a 1.4-times higher risk for being diagnosed with prostate cancer and a 2- to -3 times higher risk for dying of prostate cancer. Men with a family history of prostate cancer are at increased risk. Those at increased risk should be screened. If you are between 50 and 74 years of age, consider these factors and talk to your doctor or other health care provider.